7.4.2 Drugs for urinary frequency, enuresis, and incontinence

The Bladder and Bowel Care Service (North Devon: 01769 575182; Exeter: 01392 208465) will often prove a useful resource in assisting in the management of these conditions. In hospitals initiation of these drugs would usually be appropriate by urology, gynaecology and elderly care. Others may wish to seek advice from these primary and secondary care resources before initiating treatment.

For children, discussion with a paediatrician is strongly recommended.

Patients with neurological problems such as MS and confused elderly may be more appropriately assessed by the Bladder and Bowel Care Service.

Urological symptoms may result from oestrogen deficiency in post-menopausal women and treatment of atrophic vaginitis with local topical oestrogens may bring about improvement. (see
7.6 Vaginal and vulval conditions)

Urinary incontinence and overactive bladder

Bladder training for 6 weeks is the first line treatment (this may be accessed via the Bladder and Bowel Care Service).

Patients with uncomplicated symptoms who fail to respond to two months of conservative measures should be referred to the Bladder and Bowel Care Service.

Chronic retention can present with frequency in the elderly. If there is doubt, arrange a bladder scan locally prior to treatment.

There is no evidence that men taking anticholinergics are more likely to progress to acute urinary retention.

Whilst successful treatment may be evident in 1-2 weeks, the elderly may take up to 6 weeks before benefit becomes apparent. It is important that patients realise that freedom from incontinence is not likely with any form of drug therapy but that a reduction in frequency and incontinence episodes is a realistic expectation of treatment.

Stress incontinence

Supervised pelvic floor muscle training for at least 3 months is the first line treatment for stress or mixed incontinence. This may be accessed through the Bladder and Bowel Care Service (North Devon: 01769 575182; Exeter: 01392 208465).
NICE Clinical Guideline 171 offers further detailed advice on management options for stress incontinence. Drug therapy is an option if surgery is not possible or is refused.

Anticholinergics should not be used for stress incontinence.

Nocturia

Exclude or manage treatable causes of nocturnal polyuria.

Advise the patient to limit fluid intake in the late afternoon and evening.

If limiting fluid intake in the late afternoon or evening is ineffective:

Low dose oral desmopressin (50micrograms oral lyophilisate)
(6.5.2. Posterior pituitary hormones and antagonists) may be considered as a licensed option to reduce nocturia in men with LUTS experiencing idiopathic nocturnal polyuria. In line with NICE guidance, low dose desmopressin (25micrograms oral lyophilisate) may also be used as a licensed option by the specialist services to reduce nocturia in women who find it a troublesome symptom.

Elderly patients, aged 65 years and over, are at an increased risk of developing hyponatremia with desmopressin treatment and may also have impaired renal function. Caution should therefore be exercised in this age group and daily doses should not be increased beyond the licensed dose.

In line with NICE, loop diuretics
(2.2 Diuretics) administered in the late afternoon may also be considered as an option in men and women, in reducing nocturia associated with nocturnal polyuria (unlicensed).

Drug treatments

Anticholinergics are used for the management of primary bladder instability, overactive bladder, urge incontinence and mixed incontinence but should not be used for stress incontinence.

Modified release: Initially 5mg once daily, adjusted according to response in steps of 5mg at weekly intervals; maximum 20mg once daily

Notes

Do not offer oxybutynin immediate release to frail older patients.

Oxybutynin immediate release tablets may be particularly suitable for those who wish to take medication on an occasional basis or to titrate doses themselves. If these have failed, there is little benefit trying tolterodine or MR preparations.

Darifenacin

Tablets modified release 7.5mg, 15mg (£25.48 = 7.5mg daily)

Dose

7.5mg once daily, increased to 15mg once daily after 2 weeks if necessary

Notes

See SPC for dosing recommendations/contraindications in hepatic impairment and with concomitant use of certain medications.

Mirabegron

Tablets modified release 25mg, 50mg (£27.07 = 50mg daily)

Dose

50mg once daily

Notes

Mirabegron is recommended for patients in whom antimuscarinic drugs are contraindicated, clinically ineffective, or have unacceptable side effects. It is expected that the majority of patients would have tried and failed on at least one formulary choice antimuscarinic drug before being prescribed mirabegron

Mirabegron should be used with caution in patients with a history of QT-interval prolongation or in those patients also taking drugs that prolong the QT interval

Mirabegron is contraindicated for use in patients with severe uncontrolled hypertensive patients (systolic blood pressure 180 mm Hg or greater and/or diastolic blood pressure 110 mm Hg or greater). Blood pressure should be measured before and during treatment, especially in patients with hypertension.

Renal impairment: avoid if eGFR is less than 15mL/min/1.73m2. If eGFR is 15-29mL/min/1.73m2 reduce dose to 25mg daily. See SPC for further dosing recommendations in renal impairment and concomitant use of certain medications.

Hepatic impairment: avoid in severe impairment. Reduce dose to 25mg once daily in moderate hepatic impairment. See SPC for further dosing recommendations in renal impairment and concomitant use of certain medications.